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In addition to the Centers for Disease Control and Prevention, the principles outlined in this document have been endorsed by the American Academy of Family Physicians and the American College of Physicians–American Society of Internal Medicine.

Annals of Internal Medicine encourages readers to copy and distribute this paper, providing such distribution is not for profit. Commercial distribution is not permitted without the express permission of the publisher.

Acknowledgments: External review has included feedback from the Centers for Disease Control and Prevention; the Clinical Efficacy Assessment Subcommittee; and representatives of the American Academy of Family Practitioners, the American College of Emergency Physicians, and the Infectious Diseases Society of America. Feedback was also provided by Paul Little, MD, an expert in pharyngitis treatment, as well as full-time practicing physicians.

Role of the Funding Sources: The Centers for Disease Control and Prevention provided partial support for the development of the principles and required final approval of all manuscripts submitted for publication. Dr. Cooper is supported in part by a National Research Service Award (F32 HS00134-01) from the Agency for Healthcare Research and Quality.

The following principles of appropriate antibiotic use for adults with acute pharyngitis apply to immunocompetent adults without complicated comorbid conditions, such as chronic lung or heart disease, and history of rheumatic fever. They do not apply during known outbreaks of group A streptococcus.

1. Group A Î²-hemolytic streptococcus (GABHS) is the causal agent in approximately 10% of adult cases of pharyngitis. The large majority of adults with acute pharyngitis have a self-limited illness, for which supportive care only is needed.

2. Antibiotic treatment of adult pharyngitis benefits only those patients with GABHS infection. All patients with pharyngitis should be offered appropriate doses of analgesics and antipyretics, as well as other supportive care.

3. Limit antibiotic prescriptions to patients who are most likely to have GABHS infection. Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria: history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy [lymphadenitis]. Do not test or treat patients with none or only one of these criteria, since these patients are unlikely to have GABHS infection. For patients with two or more criteria the following strategies are appropriate: a) Test patients with two, three, or four criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results; b] test patients with two or three criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results or patients with four criteria; or c) do not use any diagnostic tests, and limit antibiotic therapy to patients with three or four criteria.

4. Throat cultures are not recommended for the routine primary evaluation of adults with pharyngitis or for confirmation of negative results on rapid antigen tests when the test sensitivity exceeds 80%. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for monitoring the development and spread of antibiotic resistance, or when such pathogens as gonococcus are being considered.

5. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin in a penicillin-allergic patient.

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